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    WHO Kesling

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    of 56
    ‘This report contains the collective views of ax intemational ‘group of experts and does not necessarily represent the deci= sions or the stated policy of the World Health Organization. WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES No. 439 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES : THEIR PLANNING, ORGANIZATION, AND ADMINISTRATION Report of a WHO Expert Committee WORLD HEALTH ORGANIZATION GENEVA 1970 © World Health Organization 1970 Poblications of the World Health Organization enjoy copyright protection in sccordance with the provisions of Protocol 2 of the Universal Copyright Convention. Nevertheless governmental agencies or learned and. professional. societies may reproduce data or excerpts or illustrations from them without requesting an authori- zation from the World Health Organization. For rights of reproduction or translation of WHO publications iv ro, applica tion should be made to the Division of Editorial and Reference Services, World Health Organization, Geneva, Switzerland. The World Health Organization weleomes such applications. ‘The designations employed and the presentation of the material in his publication ‘do not imply the expression of any opinion whatsoever on the part of the Dizector- General of the World Health Organization concerning the lgal status of any country ‘or territory oF of its authorities, of concerning the delimitation of its frontiers. ‘The mention of specific companies or of certain manufacturers’ products does ‘aot imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature which are not mentioned, Errors and ‘omissions excepted, the names of proprietary products are distinguished by initial capita Tetters. [PRINTED AN FRANCE CONTENTS ntradustion . wee General considerations ©... . Present trends in enviconmental health 5. 31 Impact of asince and technology 32 Backlog of needs... 5 33 S20pe of environmental health Planning . 41 Identification of probleme = 42 Detation of the major problems 43. Establishment of objectives oa 44 Formulation of policies 45° Relationships, of environmental, beath programmes 10 allonal healt planning and socio-economic plannibs 46. Seting priorities in environmental health 47 Manpower, tsining, and material resourees ‘i 48. Financing 49 Lerisation «2. 5 : : Organization and administration 45.4 Technical and administrative relationships 52 Implementation of environmental health programmes Ternational collaboration... 5. s . 61 Common problems of environmental health 62. Bducation . 5 63 Research 64 Hxchange of information es 65. The role of international organizations Technical needs and problems requiring future action 74 rousing interest in environmental health 72 Sues os. es ‘i aa 73 Education and training 74 Rewarch os. . aoa 1S Advisory services for planning snd implementing ensiron- ‘mental health prograsimes and other actties Summary end recommendations Acknowledgements - WHO EXPERT COMMITTEE ON THE PLANNING, ORGANIZATION, ‘AND ADMINISTRATION OF NATIONAL ENVIRONMENTAT HEALTH PROGRAMMES Geneva, 3-11 June 1969 Members :* Profesor J. M. de Azevedo Netto, Professor of Sanitary Fngineering, Faculty of Hygiene and Public Health, University of Sd0 Paulo, Brazil Professor P. N. Burgasov, Deputy Minister of Health of the USSR, and Chief Sanitary Physician, Ministry of Health of the USSR, Moscow, USSR Professor C. Chayabongse, Deputy Secretary-General, National Economic Devel ‘opment Board, and Professor of Sanitary Engincering, Faculty of Public Health, Bangkok, Thailand ‘Mr C. de Cle, Director of Town Planning and Slum Clearance, Minisry of Housing and Town and Country Planning, The Hague, Netherlands Mr. A. Eshete, Director-General, Division of Environmental Health, Ministry of Public Health, Addis. Ababa, Ethiopia Mr W. E. Gilbertson, Deputy Secretary for Environmental Protection, Depast- ‘ment of Health, Commonwealth of Pennsylvania, Harrisburg, Penn., USA (Chairman) Dr. M, Hashimoto, Chief, Environmental Pollution Control Section, Bureau of Environmental Sanitation, Ministry of Health and Welfare, Tokyo, Japan Mr C. de Lact, Secretary-General, Canadian Council of Resource Ministers, Montreal, Canada Me B. Lartey, Co-ordinator of Industrial Research, Councit for Scientific and Induseial Research, Accra, Ghana (Rapporteur) Mr 0. 0. Oladapo, Deputy Senior Engineer, Lagos Executive Development Board, Lagos, Nigeria Professeur R. Sonault, Professor of Hygiene and Social Medicine, Faculty of Medi- ine, University of Naney, and Director, Regional Hygiene Institute, Nancy, France (Vice-Chairman) ‘Seeretariat Me C. H, Atkins, Direstor, Division of Environmental Health, WHO, Geneva, Switzerland Me P. B. Brace, Reader in Public Health Engineering, Imperial College of Science and Technology, University of London, England (Consultant) Dr V, Kalaidziey, Vice Minister of Health, Ministry of Public Health, Soa, Bulgaria (Temporary Adviser) Me J. N. Lanois, Chef, Sanitation Services and Housing, Division of Environmental Health, WHO, Geneva, Switzerland (Secretary) Mr. A. K. Roy, Chief Engineer, Local SolfGovernment Engineering Department, TLucknow, Utiar Pradesh, India (Consultant) * Unable to attend: Mr M. Assar, Under-Secretary of State for Planning and Programmes, Ministry of Public Health, Teheran, Tran -4- Wid Hlth Org. techn. Rep. Ser., 1970, No. 439 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES : THEIR PLANNING, ORGANIZATION, AND ADMINISTRATION Report of a WHO Expert Committee A WHO Expert Committee on the Planning, Organization, and Administration of National Environmental Health Programmes met in Geneva from 3 (0 11 June 1969. Dr P, Dorolle, Deputy Director-General, ‘opened the meeting on behalf of the Director-General and welcomed the participants. 1. INTRODUCTION In September 1949 the first WHO Expert Committee on Environ ‘mental Sanitation explored ways and means of improving the deplorable sanitation conditions that prevailed in most parts of the world after the Second World War. The Committee's report ! has been used extensively as a guide in the planning and organization of national environmental sanitation programmes during the past two decades. Since its publica- tion there have been a number of new trends and developments in the control of environmental health, in the respective roles of health and other administrations in environmental health planning, and in the effective co-ordination of environmental health programmes at the national level ‘At present WHO is placing much emphasis on national health plan- ning, and the present Expert Committee was convened in order (1) to review modern trends in the scope, planning, and administration of national environmental health programmes, (2) to identify and discuss the nature of the technical and administrative relationships involved, (3) to develop broad guidelines for the organization of these programmes, and (4) to recommend ways of integrating and co-ordinating the planning and imple- mentation of such programmes. One of WHO's main functions, as stated in its Constitution, is to assist governments, upon request, in strengthening health services and in promoting the improvement of environmental sanitation. A programme 3 Wa Hit Org. techn, Rep. Ser. 1980, No. 10. 6 [NATIONAL ENVIRONMENTAL, HEALTH PROGRAMMES. of environmental health has been carried out steadily since 1948, and in 1968 alone more than 60 countries received assistance. In. recent years it has been necessary to give primary emphasis to specific elements of the over-all environmental health plan, e. g., community water supply, but the Organization’s central objective will not be fuliled until all member states have the necessary facilities, competence, and plans to carry out adequate and co-ordinated environmental health programmes. ‘The close relationships between environment and health have been increasingly recognized and stressed in recent years, especially in economic- ally developed nations, which are facing acute problems of environmental pollution caused mainly by chemical and physical contaminants of water, air, and soil. For many years to come biological contamination will remain the main problem of environmental health in most developing countries, although other types of pollution are rapidly increasing. and need to be controlled before they get out of hand. The importance of planning in national environmental health pro- grammies and the difficulties involved in such planning should be recog- nized. ‘The principal difficulties usually concern the establishment of realistic objectives and priorities, the adoption of modern concepts of national legislation, the multidsciplinary approach to new environmental health problems, and the financing of capital projects. Many govern- ments need advice on these questions and often turn to WHO for assistance, 2. GENERAL CONSIDERATIONS ‘The earth and its atmosphere form a closed environmental system, except for an energy input, mainly solar, and a roughly corresponding energy loss. Within this system have evolved a multitude of living orga- nisms, all of which may be viewed individually as open systems, ingesting and expelling matter, absorbing and expending energy. These living ‘organisms compete with cach other for the matter and energy they require in order to survive. Man himself is subject to this competition and it isa mistake to think that he dominates his environment; he is influenced by his environment as much as he influences it. In general, he is in balance with it, but under unfavourable circumstances this balance may be upset. For the purposes of this report, environmental health refers to the ecological balance that must exist between man and his environment in order to ensure his well-being. This well-being concerns the “whole man” —not only his physical health but also his mental health and the optimum social relations within his environment. In the same way it concerns the “whole environment”, from the individual human dwell- ing to the entire atmosphere. REPORT OF A WHO EXPERT COMMITTEE 1 As soon as the conditions necessary to maintain the ecological balance are no longer fulfilled, man crosses a “ threshold ” and has to take correc- tive measures. If he fails to do s0, some factor that normally contributes to his welfare may turn into a menace. Inevitably man’s relationship to his environment changes constantly, and needs unceasing surveillance and control, ‘The causes of the changes are well known. They include population growth, urbanization, indus- trialization, the rapid development of technology, and man’s increasing demands as his standard of living rises. ‘Communicable diseases have always required environmental control; social, economic, and technological changes have now brought such additional problems as (a) chemical and biological insults to man by industry and agriculture, (6) radiation hazards, (¢) noise, (4) the despoliation of town and country by wilful or careless actions, and (e) overcrowding, In this process of change the social element is becoming more and more important, The greatly accelerated pace of environmental change is reducing the dependence that man has hitherto been able to place on the resilience and adaptive capacity of the human organism. He is therefore forced to be more and more watchful for changes that may be harmful to him, and to take prompt steps to restore a stable and satisfactory balance, Vigilance is particularly necessary to detect such insidious changes as the building up of dangerous amounts of insecticides in vegetable and animal life and hence in human food, As nations move towards higher stages of development and indus- ttialization, they meet a whole new range of environmental problems. ‘The problems are not always encountered in the same form, in the same order, or at the same pace. Moreover, different areas of one nation’s territory may, at any given time, have reached quite different stages of development, Accordingly, this report deals with the whole range of problems within the field of environmental health, and indicates how solutions and remedies may be found. Three types of action are desirable : (1) Whenever possible, environmental health hazards should be prevented from occurring. (2) Where hazards already exist or are inevitable, steps should be taken to minimize or if possible eliminate their ill-effccts, (3) The creation of healthy surroundings (good housing, recreational facilities, etc.) should be encouraged, especially in densely populated areas Environmental control programmes should pay particular attention to the well-being of the very young, because the first two or three years of a person's life may be critical for all his further development. 8 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES 3. PRESENT TRENDS IN ENVIRONMENTAL HEALTH. ‘The early objectives of environmental health programmes were con- fined almost exclusively to the prevention and control of communicable diseases, which were transmitted through clearly identifiable features of the physical environment, such as water and human wastes. These ob- jectives romain valid today, but have now been joined by a host of others. Environmental hazards to human health and well-being are becoming more complex, more far-reaching and more subtle. At the same time a new concept of environmental health is being developed, which includes not only the wide control of environmental hazards but also the development of optimum environmental conditions that will contribute positively to man’s health and welfare. 31 Impact of science and technology Science and technology are reshaping civilizations and altering living standards in all parts of the world. The potentials in terms of goods and services, production and distribution, are enormous. Advances in communications make the world appear smaller, and changes in one area promplly trigger off changes in other areas, Space travel and under- sea exploration are adding new dimensions to our ideas of the human environment. However, science and technology also provide the means for counter- acting undesirable by-product effects. Qualified personnel, and resources and facilities for analysis, diagnosis, and monitoring are becoming avail- able on a wider scale, More economic sources of energy, together with miniaturized control systems, constitute additional tools for environmental control. Space research is producing an extraordinary range of remote “sensory” techniques which have been borrowed for use in agriculture, in forestry and, to a limited extent, in mining operations. Improved methods incorporating high degree of automation are being used in chemical analyses, especially those of fresh and marine, surface and under- ground waters. 3.2 Backlog of needs 3.2.1 Environmental problems in developed areas In most of the developed areas of the world, considerable progress hhas been made with the provision of the basic environmental health ser- ‘vices — housing, water supply, and the disposal of liquid and solid wastes — although much remains to be done in this respect. Several developed REPORT OF A WHO EXPERT COMMUFTEE 9 countries have found it necessary to shift the emphasis of environmental health programmes to other matters, such as the control of atmospheric pollution and pollution by new chemical substances, accident reduction, and the amelioration of living conditions in large cities. Special problems arise in overcrowded and badly-housed areas of cities, including noise, vehicle fumes and accidents, and social and mental stresses that can lead to delinquency and crime. Future environmental control activities should be directed to the improvement of mental and social as well as physical health. Tn order to achieve the complete well-being of man, action must be extended to the entire environment; already environmental health workers are exerting a strong influence on housing, architecture, town planning, industrial design, recreational facilities, etc, 3.2.2 Environmental problems in developing areas A WHO study of the state of community water supplies in 75 develop- ing countries ! revealed that more than 70% of the urban dwellers in these countries lacked adequate and safe water. Only 5 or 6 of the countries were providing new water supplies at a rate sufficient to keep pace with the increase in urban population. In few, if any, of these countries was the backlog of water supply needs actually being reduced, In the urban sectors of developing areas, enviconmental health pro- grammes are still largely restricted to work in water supply and in the sanitary disposal of liguid and solid waste. However important these activities may be, such limitation of the environmental health programme may be qiuite inconsistent with the:country’s other health needs and may bbe detrimental to its socio-economic development. The rapid development of communications and the fact that food produced in one country is, consumed in another increase the population at risk and justify wider scope for environmental health programmes in the developing arcas. There is likely to be a setback in trade in food from such areas if food sanitation is not emphasized. Moreover, the economy of some of the developing areas is closely connected with tourism. and tourists demand high standards in water supply, waste disposal, food sanitation, accommo- dation, public recreation, and vector contol In the rural sectors of developing areas, too, environmental health programmes have mainly been confined to the provision of safe water supplies and the disposal of raw excreta. While these are no doubt the most pressing problems, it must be recognized that the improvement of water supplies creates a need for proper disposal of used and waste water, 2 Dieterich, B. H, & Henderson, J. M. (1963) Urban water supply conditions and needs in sevent-five developing counties, Geneva, World Health: Organization (Piel, Hlth Pap., No. 23). 10 NATIONAL PNVIRONMENTAL HEALTH PROGRAMMES In areas affected by schistosomiasis a particularly thorough approach to the problem of water, food, and soil infestation is required. ‘The housing of rural populations is another field of environmental health that requires more attention. ‘Most of the countries commonly described as “ developing” contain areas of high urbanization and industrialization as well as contrasting poorly-developed regions. They are therefore facing, or are about to face, many of the environmental health problems that have confronted the industrially advanced nations for many years. They have the oppor- tunity to learn from the successes and failures of the more developed nations and to make the most advantageous use of the knowledge that hhas been gained, 3.3 Scope of environmental health Environmental health is considered by the Committee to include or relate to the following : (1) Water supplies, with special reference to the provision of adequate quantities of safe water that are readily accessible to the user, and to the planning, design, management, and sanitary surveillance of community water supplies, giving due consideration to other essential uses of water Q) Waste-water treatment and water-pollution control, including the collection, treatment, and disposal of domestic sewage and other water-borne wastes, and the control of the quality of surface water (includ- ing the sea) and ground water. @ Solid-waste management, including sanitary handling and disposal. (@ Vector control, including the control of arthropods, motluses, rodents, and other alternative hosts of disease, (5) Prevention or control of soil pollution by human excreta and by substances detrimental to human, animal, or plant life (©) Food hygiene, including milk hygiene. (1) Control of air pollution. (8) Radiation control ) Occupational health, in particular the control of physical, chem- ical, and biological hazards. (10) Noise control (11) Housing and its immediate environment, in particular the public health aspects of residential, public, and institutional buildings. REPORT OF A WHO EXPERT COMMITTEE u (12) Urban and regional planning. (13) Environmental health aspects of air, sea, or land transport (14) Accident prevention. (15) Public recreation and tourism, in particular the environmental health aspects of public beaches, swimming pools, camping sites, ete. (16) Sanitation measures associated with epidemics, emergencies, disasters, and migrations of populations. (17) Preventive measures required to ensure that the general environ ment is free from risk to health All the items in this list are already included in various degrees and combinations in environmental health programmes in various parts of the world, ‘The Committee also took note of the problems associated with the closed environmental systems used in space travel and in deep- sea exploration. At present few countries are engaged in such activities, and the number of individuals affected is small, but this field must be expected to expand and will eventually concern environmental health workers. 4. PLANNING Planning is a process by which available data, needs, and resources are appraised and analysed, and used in preparation for change. The need for planning in the closely related fields of urban development and environmental health was fully discussed in the report of a WHO Expert Committee on Environmental Health Aspects of Metropolitan Planning and Development. 1 Carefully co-ordinated planning is essential for the following reasons (1). There is now a lack of space for disposing of waste products, whether on or under the ground, in water or in the air, without infringing on the health rights or properties of others. 2) Man’s ability to disturb or alter the great forces of nature has increased to the point where mistakes or unknown eflects may have disas- trous and perhaps irreversible consequences. None of our natural resources is in so great supply that it can be considered inexhaustible. (4) The process of biological adaptation through selection and genetic development takes generations, whereas environmental changes of large magnitude now take place within a few years. Wd Hck Org. techn, Rep. Ser. 1965, No. 297 12 [NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES (8) Environmental protection has not yet attracted sufficient effort from the scientific and engineering communities or from society in general. (6) There is a need for stronger commitment to environmental health fon the part of public bodies, and their efforts will require careful preparation, ‘The Committee considers that, in national health planning and develop- ‘ment, environmental health should be accorded equal emphasis with the personal health services. Environmental health programmes should be planned on the broadest scale, aiming at the complete wholesomeness of the environment and at comprehensive community health. To achieve this aim, environmental health workers will have to develop a multi- disciplinary approach, working in harmony with politicians, political scientists, sociologists, economists, educational psychologists, physical planners, lawyers, and so on, as well as with members of the various pro- fessions directly concerned in public health. 4.1 Identification of problems ‘The important problems of environmental health can be identified by a study of health statistics relating to : (1) the type and incidence of those diseases that are caused ot affected by environmental factors; 2) the impact of environmental factors on life expectancy; () the general state of physical, mental, and social well-being in relation to environmental factors. ‘The necessary data must be drawn from all available sources, such as (a) vital statistics; (6) mortality and morbidity statistics; (c) demographic Statistics; (@) life tables; (@) school health statistics; (') medical care Statistics; (g) insurance benefit statistics (ez, health, workmen's compensation, accident insurances, etc.); and (hi) results of any special investigations by government departments, universities, etc. In order to assess the significance of these statistics in relation to environmental factors, itt’ may also be necessary to study information obtained in many related fields. The environmental factors concerned can be classified as follows Natural Physical, ait, water, soil, space, sunlight Biological, ic, plants and animals, including micro-organisms Socio-cconomic, e.g., housing, land use and plansing, transportation, the level and pattern of production, food, industries, social relations, cultural conditions. REPORT OF A WHO EXPERT COMMITTEE 13 Information on these elements of the environment must be sought from a variety of sources in government departments and elsewhere, and will include environmental pollution measurement data, water resource statistics, industrial and agricultural statistics, food and nutrition statistics, consumer statistics, transportation and trafic statistics, and so on, Such data will reveal a broad and complex pattern of man’s relation ship to his environment. Environmental health epidemiology will supply important numerical information for the problem-defining process. Never- theless, the amount of data available is sometimes limited and the accuracy of data is in some cases doubtful. Problems can also be defined on the basis of the felt and expressed needs for environmental health programmes. The basic and minimum needs in environmental health, of course, are safe and adequate drinking, water supplies and proper disposal of human exereta. In addition, people have varying needs for safety, comfort, convenience, and aesthetic quality in their living environment. In practice, the needs-oriented approach is sometimes more workable as a means of defining the problem and luencing the civil servants and politicians who make decisions. These two approaches, the supply-oriented and the needs-oriented, are indispensable for the planning of environmental health programmes. The particular merits of each kind of approach should be kept in mind. Any gaps or discrepancies between them should be minimized by taking the greatest possible advantage of the multidisciplinary team approach, 42 Definition of the major problems ‘Many of the major environmental health problems have already been identified and discussed by WHO Expert Committees. In the mean- time new problems have arisen and the old ones have become more serious ‘owing to uncontrolled urbanization, the increasing pace of industrializa- tion, the development of transport systems, and, particularly in the chem= ical industry, the application of new technological processes. The solution of the environmental health problems that we face today, and will face in the years ahead, depends on many factors, such as technological feasibility, governmental policy in relation to socio- economic development, financial resources, administrative operations (planning and implementation, evaluation, organization and management), and different social factors, The following paragraphs contain a brief description of some of the outstanding current environmental health problems 1 Wd Tih Org. tec. Rep. Ser, 1950, No. 10; 1954, No. 77; 1965, No, 297 4 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES 4.2.1 Community. water supply ® As water is so very important for human consumption and other domestic and public uses, the provision of community water supplies will long remain one of the major objectives of environmental health programmes in developing countries. Trained personnel, and a sound organizational structure for the planning, design, management, operation, and maintenance of water-works, are the basic prerequisites for attaining, this objective, Moreover, as the provision of community water supplies, for the whole population entails a financial outlay beyond the reach of many developing countries, it is imperative to study the most economical solutions and to design efficent, but inexpensive, installations. 4.2.2 Waste-water treatment and water-pollution control? ‘Water pollution is increasing throughout the world and the safe coll- ction and disposal of domestic sewage remains one of the major tasks confronting the developing countries. In many areas of the world human excreta are still being disposed of in shallow latrines, into water-courses, or on the surface of the ground, or night-soil is dumped from buckets into the soil or water. In view of the prohibitive cost of building and operating modern sewage treatment plants, every effort should be made to adopt simple and cheap methods, such as lagoons and oxidation ponds, where the conditions are suitable. In more developed areas, industrial wastes and “ microchemical ” pollution are becoming more and more prominent, in contrast to the developing countries where most water pollution is still biological Control of water pollution cannot be separated from the planning and management of a country’s water resources. Since in most cases several different water pollution control programmes are feasible, the modern techniques of operational research and systems analysis are being increasingly applied to select the optimum programme from both the technological and economic viewpoints. In addition to waste-water treatment before discharge, other pollution control techniques being applied include the controlled discharge of wastes, the regulation of river flows, and the improvement of the self-purification capacity of bodies of water, In densely populated and highly industrialized areas, as well as in some arid regions, the re-use of treated waste water is increasingly prac~ tised. This requires careful environmental surveillance to prevent inci- dental health hazards, 3 See also Wid Hlth Org. techn. Rep. Ser., 1968, No. 420 2 See also Wid Hlth Ong. techn, Rep. Ser 1966, No, 318; 1967, No. 367; 1968, No. 404 REPORT OF A WHO EXPERT COMMITTEE 15 423. Air pollution | ‘The degree of air pollution varies according ta population density, industrial development, geographical situation, social and economic structure, and local customs, The contaminants arising from human activities (power production, the metallurgical and petrochemical indus- tries, and transport) include sulfur oxides, nitrogen oxides, carbon mon- oxide, soot, and other compounds; they have clearly defined effects on vegetation, property, and local climate, and are also believed to have adverse effects on human health. However, much more work is needed to prove that normal levels of air pollution as found in urban areas are associated with increased disease, Air pollution control by such methods as the removal of contaminants from flue gases is possible in many instances, but the application of such methods may be restricted owing to the high cost of the equipment in- volved. Other measures for air pollution control include the use of alternative fuels, the adoption of district or central heating, and the care- ful siting of highways, factories, etc. in relation to residential areas. 42.4 Soil pollution ‘The principal cause of soil pollution is the release of liquid and solid ‘wastes on or into the ground, In the rural areas of many developing coun- tries the soil is often polluted by the dumping of human excreta directly on the ground, while in highly populous areas the use of soakaways and ‘the improper disposal of septic tank effluents also contribute to such pollution. Bacterial and parasitic diseases, e.g., asceriasis, can be spread in this way. As is now obvious in many of the industrially advanced countries, soil can also be polluted by nondegradable substances such as wastes from the mining industry, by petroleum products, by persistent, pesticides used in agriculture, and by radioactive wastes. Some of these pollutants destroy plant life, while pesticides, for example, may be trans- mitted to man through the food chain. 423. Solid wastes management ® Changing patterns in man’s life and activity result also in changes in the production and composition of solid wastes. In the past solid ‘wastes were mainly domestic, but today they are also produced in large ‘quantities by industry. Indeed, in some industrialized countries an aver- age of 700 kg of solid wastes is produced per person per year, * See also Barker, K. et al. (1961) lr pollution, Geneva (World Health Organiza- tion: Monograph Series, No. 46); and Wid Hlth Org. techn. Rep. Ser, 1968, No. 271 = See also Wid Hlth Org. techn. Rep. Ser, 1967, No. 367. 16 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES ‘Some of the solid wastes produced by modern civilization pose special difficulties on account of their nondegradability (e.g., plastics), toxicity (e.g, many industrial and chemical residues), or size (c.g, abandoned motor-cats and large household goods). The problem is not only one of disposal, but of collection, storage, and processing so that, if at all possible, the final product may be of some economic benefit to the ‘community. Tris worth noting that attempts to solve a liquid wastes problem may lead to a solid wastes problem, i. e., disposal of sludge, while the incinera- tion of solid wastes leads to the problem of air pollution, 4.2.6 Food control? ‘As so many forms of disease and poisoning can be transinitied by food, measures are needed to ensure the safety, wholesomeness, and cleanliness of food at all stages, from growth through processing to consumption. The level of food hygiene varies greatly from one country to another. Where no effective measures have as yet been taken, the primary problem is to establish simple and effective schemes for the supervision of those foods — such as meat, eggs, milk and milk products, fish, shellfish, and salads — that could be carriers of biological or chemical disease-producing agents. Control methods are well known (supervision of the delivery, display, and serving of food to the public, the training of food-handlers, the destruction of rodents and other vermin, and the elimination of pesticide, antibiotic, and other chemical residues), but efficient admini- strative organization is not an easy problem. Elicient food sanitation results in savings in the cost of medical care, increased productivity, and a reduction in food spoilage, so making more food available for human consumption. 4.2.7, Vector control ‘The advent and application of new pesticides has made considerable progress possible in this field. As a result, however, new resistant species of vectors have emerged. Several other control techniques are being contemplated, including genetic modifications in insect vectors. More knowledge is needed about the ecology of these transmitters of disease. It must not be overlooked that many pesticides are also highly toxic to man, so that their use creates a further need for environmental precautions. 4 See also Wid Hlth Org. techn. Rep. Ser. 1986, No, 104; 1962, No, 241; 1967, No. 370; and Abdussalam, M. et al. (1962) "Milk hygiene, Geneva (World Health Organisation: Monograph Series, No. 48). REPORT OF A WHO EXPERT COMMITTEE a 4.2.8 Protection of the population from radiation ‘To safeguard man’s environment against radiation hazards is a major problem that will become more serious in the future with the rapid ex pansion of the nuclear power industry Environmental effects of this industry are chiefly due to pollution resulting from releases of radioactive wastes (including solid, liquid, gase- ‘ous, and aerosol discharges) and from accidents. Such pollution involves water, air, soil, and food resources. Nuclear power production may also aggravate thermal pollution of rivers by the discharge of large volumes, of cooling water. ‘The following uses of atomic eneray in the foreseeable future should bbe taken into account in environmental health programmes : (1). Replacement of fossil fuels by nuclear fuels, leading to potential contamination by radioactive wastes from fuel processing, from the pro- duction of artificial radionuclides and, especially, from reprocessing plants, Reactor accidents might occur in fixed reactors or in nuctear- powered ships, submarines, and future space vehicles. (2) Applications of radioisotopes in medicine, industry, agriculture, and research. The over-all contamination from these sources is likely to be much less than that from the nuclear power industry, but control and supervision are nevertheless essential (3) Various peaceful uses of nuclear explosives. These should be considered in environmental programmes, largely because of public ‘concern and the need to allay fears. In addition, attention should be given to hazards arising from non- ionizing radiation, such as those encountered in the use of micro-waves in ovens, radar, television, etc, 4.29 Noise Noise was first recognized as a problem of industrial health, but its importance as a community problem is growing. Industry, land and air transport, the construction of buildings, and the use of radio and television seis are some examples of the sources of noise pollution in resi- dential areas. In the future we way have to face additional problems, such as the “ supersonic boom ”. ‘The health hazards attributable to community noise are not clear, but since it is an additional environmental stress it may well be one of the causes of the increase in mental and behavioural disorders. 2 See also Bell, A. (1966) Noise, Geneva, World Health Orgsnization (Publ. Hlth Pap., No. 30), 18 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES The control of community noise is a difficult problem; it has been suggested that administrative and legal measures, suitable location of industry, and town planning may reduce noise levels in residential areas. 4.2.10 Occupational hazards Problems of occupational health merit great attention. By the nature of their jobs, some workers in industry and agriculture are exposed to dangers and influences that can damage their health. The factors involved include toxic substances, dust, vibration, noise, fumes, and radiations. ‘Machines and processes must be designed so as to minimize the danger of accidents; adequate lighting, ventilation, temperature, and humidity control are also important, Special attention must be paid to the working conditions of women and young people. 4.2.11 Human settlements and the general environment Environmental health planning should cover the total human envicon- ment, including town planning and architecture. The rural environment should be considered separately from the urban environment. ‘Two-thirds of the world’s population live and work in rural areas; this in the developing countries usually implies poverty. Rural areas have a characteristic pattern of health and disease, the prevailing diseases being vector-borne, caused by micro-organisms or by malnutrition, Indeed, malnutrition is so widespread that it has come to be identified as the main obstacle to social and economic progress. Other salient factors of the rural environment are poor general sanitation, poor housing, and poor personal hygiene associated with inadequate water supplies. In many respects the town dweller is more privileged than his rural counterpart; hence the continued and uncontrolled migration from rural to urban areas, leading in turn to congestion and to the growth of slums and shanty towns outside the large cities. ‘The stress of city life may overwhelm the newcomers, but such are the prospects of economic and social advancement that the cities will keep on growing for a long time to come. Better town planning and housing, improved sanitation and health services will reduce the adverse effects of the urban environment. Easily accessible recreational areas will also be needed, for the process of development means shorter working hours and more leisure time. 43. Establishment of objectives ‘No planning can be undertaken successfully unless a clear objective is in view. In the case of environmental health planning the objective ccan be simply stated as the promotion of complete physical, mental, and social well-being, so far as this can be achieved by environmental control REPORT OF A WHO EXPERT COMDITTEE 9 More limited targets need to be fixed as intermediate steps towards the ultimate objective; a time scale should also be decided upon, since an objective stated in absolute terms may not be helpful in the formulation of policies. In broad terms, the four main stages in environmental health activity hhave been defined by the Americani Public Health Association as follows “1, Insuring the elements of simple survival; 2. Prevetion of disease and poisoning; 2. Mainainiag an environment suited to man’s eficent performance; 44 Presecvation of comfort and the enjoyment of living.” In any practical plan, of course, intermediate objectives will need to be established for shorter time intervals and for the various sections of a programme; they’ should be expressed either in terms of health standards to be achieved or in terms of physical work to be carried out. 4.4 Formulation of policies ‘The Committers recognizes that policies in environmental health must be made consonant with other social objectives. Further, they must fit into the political and administrative framework within which they will be implemented, ‘The formulation of policies should be the result of thorough planning and of @ constant reappraisal of the alternatives suggested by changing circumstances. It may be added that public awareness of impending problems in environmental health is becoming more evident: this should be encouraged as it can make a significant contribution to the development of meaningful policies. Clearly, environmental health policies cannot be made to vield all- encompassing “ ideal” solutions. An added difficulty is that policies must often be based partly on arbitrary definitions and subjective impres- sions and judgements. It is therefore not surprising that in many instances, certain limited objectives are difficult to reconcile. It is clear that such a varied set of policy components cannot be all- inclusive and is not easy to integrate into a meaningful whole, While recognizing this, the Committee draws special attention to the following points (1) Improvement programmes in environmental health must be related to other government priorities and to other health programmes in particular. (2) Government and other public agencies responsible for carrying out policy decisions must be strengthened and given every facility to 1 Stead, F. M. (1960) Amer. J. publ. Hith, $0, 312. 20 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES. promote the public’s recognition and understanding of the environmental health implications of their activities. Every member of society and every sector of the community has a responsibility to help preserve the quality of the environment, (3). It is necessary to monitor and control environmental conditions, and the Commitize recommends that possible surveillance requirements be identified early in the formulation of environmental health policies. 4S Relationships of environmental health programmes to national health planning and socio-economic planning ‘National health planning is widely accepted as a tool for increasing the effectiveness of health services and thus for providing the greatest number of people with maximum health benefits at the least cost. Its objective is the orderly development of all services concerned with the promotion and restoration of health and the prevention of disease. Since raising the level of health is also an aid to economic progress, national health planning must be integrated into socio-economic development planning, although the value of human life and health for their own sakes must never be lost sight of. Environmental health programmes are components of comprehensive health programmes, and their planning should therefore be an integral part of national health planning. It is recognized, however, that not all environmental health programmes fall within the operational juris- diction of the health authority. Those that do not should be directly linked to national development plans, although at the same time the health authority should always be kept aware of the over-all picture of environ~ mental health planning and should strive to keep or acquire the role of promotion, co-ordination, surveillance, and control in this field The extent to which environmental health programmes are dependent ‘on socio-economic planting is highlighted in cases when large capital investment is required for the construction of important sanitary engineer ing works, or when environmental problems have to be solved on a region- al basis and resources controlled by different political authorities need to be mobilized. Economic development is itself dependent to some degree on the improvement of the environment, such as malaria control in economically important areas, and on the preservation of a healthy environment, as is required for the promotion of tourism, recreation, and business. In many of the developing countries it might be helpful, where pos- sible, to link the environmental health programme with the country’s major needs, stressing the socio-economic benefit that might accrue, A few examples are the re-use of waste water in agriculture, the development REPORT OF A WHO EXPERT COMMITTEE a of fish farms in stabilization ponds, and the use for irrigation purposes of the spare capacity of a tube well in a water-supply system. Before any programme is implemented, its employment potential and the possi- of resulting expansion of industry should also be considered in the context of national planning. A water supply, sewerage, or waste disposal programme has @ high employment potential both during construction and in operation and maintenance. Such programmes often encourage ‘other forms of community development such as the extension of electric power supplies, and their requirements for materials and equipment stim- ulate manufacturing industries whose products are also of value to other consumers, These are some of the socio-economic advantages ‘that might give an environmental health programme a higher place in national planning. ‘One of the greatest difficulties faced by environmental health plan- ners is the lack of an evident cause-and-effect relationship between the resources necessary to improve an environment and the gains in produc tivity arising from the improvement. Adequate methods need to be developed for quantifying results in social and economic terms. Eco- nomic studies would then become a meaningful part of environmental health planning, and continue into the implementation phase of programmes. Environmental health specialists should have training in economic planning, just as economic planners should be familiar with environmental health concepts and methods. This would help to bring. ‘the two disciplines into a working relationship of enduring benefit to both. In the joint planning process, particular attention should be paid to certain conditions and. procedures in order to avoid costly failures. ‘The conditions should include : (1) present and projected governmental policy (2). the stage of socio-economic development that the country has reached (3). The country’s social characteristics and the effects that progress ‘and educational programmes will have upon them. ‘The procedures considered should include : (1) sound technical feasibility studies, accompanied by accurate cost and time estimates for the various alternatives possible, in order to reach pre-determined goals; (2) keeping programmes or installations simple, which will also facilitate operation and maintenance; (3) sound financial studies to explore all sources of finance and, when appropriate, all methods to recover the initial investment and to ensure satisfactory operation; 4 2 NATIONAL ENVIRONMENTAL HEALTH PROGRAMMES (4) the establishment of sound administration, including machin- ery for continuing evaluation based on accurate recording and reporting systems, 4.6 Setting priorities in environmental health Environmental health presents a large number of problems covering every aspect of public health. ‘The resources for solving these problems are limited in all parts of the world, particularly in the developing countries. On the other hand, environmental health programmes have to compete within the national development policy with other programmes such as those for industrial development, agricultural expansion and improvement, education, and social services. It commonly happens ‘therefore that, in a given area of environmental health, a limited number of programmes must be selected on the basis of priorities. The setting of priorities may be considered from two major points of view : (1) technical considerations; @)_ public or government policy. From the technical point of view criteria for setting priorities are well established. The third report of the WHO Expert Committee on Environmental Sanitation stated : ‘While the general objective of environmental sanitation as a fundamental function ‘ofthe health department is to work towards a state of positive community health and ‘well-being, specific objectives will vary with the state of development of the community. Jin the early stages, the basic neods of environmental sanitation must be provided, but ‘as the community develops there should be a progressive expansion of sentary services 40 provide beter standards of health and improved conditions of living "The basic sanitary need of a community is the elimination of the gross causes of ‘communicable disease, which are usually an insanitary water-supply, contamination rom human excreta, and insect vectors of disease. The provision of facilities to take ‘ere of these base needs does not however offer a complete answer to the problem. “There must, in addition, be a concomitant understanding of the importance of health and an effort to practise its elementary rules. In some areas, conditions such as gross ‘overcrowding prevent improvement in health standards, and in others inadequate levels. ‘of nutrition do so, To serve this ultimate purpose sanitation must be part (albeit one ‘of the essontial parts) of a general plan of community improvement which has, as its objective, the provision of an improved standard of well-being and living ‘conditions, ‘As health standards ate raised, the comfort, attention to convenience, and efficiency ‘of the population become increasingly important, and will require further improvements in water-supply, more effective excreta disposal, and a consideration of such factors 3 refuse disposal, housing, and food and milk contol? © WFld Hlth Org. techn. Rep. Ser 1954, No. 77, p. 9. REPORT OF A WHO EXPERT COMMITIFE B These statements are still important today, and the Committee considers them a valid background to the establishment of criteria for environmental health programmes in many parts of the world, Tt has to be understood that there is no universally applicable rule for establishing priorities aud making decisions. Choices are based on various facts and considerations and may vary from country to country according to local conditions. In general, the setting of priorities may be based on a series of assess ‘ments common to any priority-

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